Page 175 - Journal of Special Operations Medicine - Summer 2015

or more major amputations, penetrating torso trauma, or – Reassess the casualty after each unit. Continue re-
evidence of severe bleeding) suscitation until a palpable radial pulse, improved
– Administer 1g of tranexamic acid in 100mL normal mental status, or systolic BP of 80–90mmHg is
saline or lactated Ringer’s as soon as possible but present.
NOT later than 3 hours after injury. 3. If in shock and blood products are not available un-
– Begin second infusion of 1g TXA after Hextend or der an approved command or theater blood product
other fluid treatment. administration protocol due to tactical or logistical
6. Traumatic brain injury constraints:
a. Casualties with moderate/severe TBI should be moni- – Resuscitate with Hextend, or if not available;
tored for: – Lactated Ringer’s or Plasma-Lyte A;
1. Decreases in level of consciousness – Reassess the casualty after each 500mL IV bolus;
2. Pupillary dilation – Continue resuscitation until a palpable radial
3. SBP should be >90mmHg pulse, improved mental status, or systolic BP of
4. O sat >90% 80–90mmHg is present.
2
5. Hypothermia – Discontinue fluid administration when one or
6. Pco (If capnography is available, maintain between more of the above end points has been achieved.
2
35–40mmHg) 4. If a casualty with an altered mental status due to sus-
7. Penetrating head trauma (if present, administer pected TBI has a weak or absent peripheral pulse,
antibiotics) resuscitate as necessary to restore and maintain a
8. Assume a spinal (neck) injury until cleared. normal radial pulse. If BP monitoring is available,
b. Unilateral pupillary dilation accompanied by a de- maintain a target systolic BP of at least 90mmHg.
creased level of consciousness may signify impending 5. Reassess the casualty frequently to check for recur-
cerebral herniation; if these signs occur, take the follow- rence of shock. If shock recurs, recheck all external
ing actions to decrease intracranial pressure: hemorrhage control measures to ensure that they
1. Administer 250mL of 3% or 5% hypertonic saline are still effective and repeat the fluid resuscitation as
bolus. outlined above.
2. Elevate the casualty’s head 30 degrees. *Neither whole blood nor apheresis platelets as these products
3. Hyperventilate the casualty. are currently collected in theater are FDA-compliant. Conse-
a) Respiratory rate 20/min quently, whole blood and 1:1:1 resuscitation using apheresis
b) Capnography should be used to maintain the platelets should be used only if all of the FDA-compliant blood
end-tidal CO between 30–35mmHg products needed to support 1:1:1 resuscitation are not avail-
2
c) The highest oxygen concentration (Fio ) possible able, or if 1:1:1 resuscitation is not producing the desired clini-
2
should be used for hyperventilation. cal effect.
*Notes: 8. Prevention of hypothermia
– Do not hyperventilate unless signs of impending herniation a. Minimize casualty’s exposure to the elements. Keep pro-
are present. tective gear on or with the casualty if feasible.
– Casualties may be hyperventilated with oxygen using the b. Replace wet clothing with dry if possible. Get the casu-
bag-valve mask technique. alty onto an insulated surface as soon as possible.
7. Fluid resuscitation c. Apply the Ready-Heat Blanket from the Hypothermia
a. The resuscitation fluids of choice for casualties in hem- Prevention and Management Kit (HPMK) to the casu-
orrhagic shock, listed from most to least preferred, are: alty’s torso (not directly on the skin) and cover the casu-
whole blood*; plasma, RBCs and platelets in 1:1:1 ra- alty with the Heat-Reflective Shell (HRS).
tio*; plasma and RBCs in 1:1 ratio; plasma or RBCs d. If an HRS is not available, the previously recommended
alone; Hextend; and crystalloid (lactated Ringer’s or combination of the Blizzard Survival Blanket and the
Plasma-Lyte A). Ready Heat blanket may also be used.
b. Assess for hemorrhagic shock (altered mental status in e. If the items mentioned above are not available, use pon-
the absence of brain injury and/or weak or absent radial cho liners, sleeping bags, or anything that will retain
pulse). heat and keep the casualty dry.
1. If not in shock: f. Use a portable fluid warmer capable of warming all IV
– No IV fluids are immediately necessary. fluids including blood products.
– Fluids by mouth are permissible if the casualty is g. Protect the casualty from wind if doors must be kept
conscious and can swallow. open.
2. If in shock and blood products are available under 9. Penetrating eye trauma
an approved command or theater blood product ad- If a penetrating eye injury is noted or suspected:
ministration protocol: a. Perform a rapid field test of visual acuity.
– Resuscitate with whole blood*, or, if not available b. Cover the eye with a rigid eye shield (NOT a pressure
– Plasma, RBCs, and platelets in a 1:1:1 ratio*, or, patch).
if not available c. Ensure that the 400mg moxifloxacin tablet in the com-
– Plasma and RBCs in 1:1 ratio, or, if not available; bat pill pack is taken if possible and that IV/IM anti-
– Reconstituted dried plasma, liquid plasma or biotics are given as outlined below if oral moxifloxacin
thawed plasma alone or RBCs alone; cannot be taken.

Tactical Combat Casualty Care Guidelines 165